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Fernandez Valledor A, Rubinstein G, Moeller CM, Lorenzatti D, Rahman S, Lee C, Oren D, Farrero M, Sayer GT, Uriel N. "Durable left ventricular assist devices as a bridge to transplantation in The Old and The New World". J Heart Lung Transplant 2024; 43:1010-1020. [PMID: 38360159 DOI: 10.1016/j.healun.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/20/2024] [Accepted: 01/31/2024] [Indexed: 02/17/2024] Open
Abstract
Heart transplantation remains the gold standard treatment for end-stage heart failure patients without contraindications. However, limited donor availability and long wait times have created a need for left ventricular assist devices (LVAD) to be used as a bridge to transplantation in appropriately selected patients. Improvements in LVAD technology have resulted in improved short- and long-term outcomes, further supporting the use of these devices for a bridge-to-transplant (BTT) indication. LVAD utilization as BTT exhibits notable disparities worldwide, mainly due to variations in organ availability, allocation policies, and financial constraints. Although Europe has experienced a consistent increase in the use of LVAD for this purpose, the United Network for Organ Sharing 2018 policy amendment resulted in a significant reduction in the number of LVADs used for BTT in the US. To overcome this issue, modifications in the US allocation policy to consider factors such as days on device support, age, and type of complications may be necessary to potentially increase implantation rates.The authors provide an overview comparing the current state of heart transplantation in the US and Europe, with a particular focus on how distinct allocation policies and organ availability impact medical practices. Additionally, the review will examine critical aspects ranging from patient selection and pre-implantation optimization to post-transplant outcomes.
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Affiliation(s)
- Andrea Fernandez Valledor
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Gal Rubinstein
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Cathrine M Moeller
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Daniel Lorenzatti
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Salwa Rahman
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Changhee Lee
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Daniel Oren
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Marta Farrero
- Heart Failure and Heart Transplant Unit, Cardiovascular Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Gabriel T Sayer
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York.
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Oren D, Uriel M, Moeller CM, Valledor AF, DeFilippis EM, Lotan D, Colombo PC, Yuzefpolskaya M, Topkara VK, Clerkin KJ, Raikhelkar JK, Fried JA, Oh DKT, Bae D, Lin E, Theodoropoulos K, Naka Y, Takeda K, Choe J, Jennings DL, Majure D, Latif F, Sayer G, Uriel N. Utility of a fusion protein T-cell co-stimulation blocker Belatacept in heart transplant recipients: Real world experience from a high volume center. Clin Transplant 2024; 38:e15251. [PMID: 38504576 DOI: 10.1111/ctr.15251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Belatacept (BTC), a fusion protein, selectively inhibits T-cell co-stimulation by binding to the CD80 and CD86 receptors on antigen-presenting cells (APCs) and has been used as immunosuppression in adult renal transplant recipients. However, data regarding its use in heart transplant (HT) recipients are limited. This retrospective cohort study aimed to delineate BTC's application in HT, focusing on efficacy, safety, and associated complications at a high-volume HT center. METHODS A retrospective cohort study was conducted of patients who underwent HT between January 2017 and December 2021 and subsequently received BTC as part of their immunosuppressive regimen. Twenty-one HT recipients were identified. Baseline characteristics, history of rejection, and indication for BTC use were collected. Outcomes included renal function, graft function, allograft rejection and mortality. Follow-up data were collected through December 2023. RESULTS Among 776 patients monitored from January 2017 to December 2021 21 (2.7%) received BTC treatment. Average age at transplantation was 53 years (± 12 years), and 38% were women. BTC administration began, on average, 689 [483, 1830] days post-HT. The primary indications for BTC were elevated pre-formed donor-specific antibodies in highly sensitized patients (66.6%) and renal sparing (23.8%), in conjunction with reduced calcineurin inhibitor dosage. Only one (4.8%) patient encountered rejection within a year of starting BTC. Graft function by echocardiography remained stable at 6 and 12 months posttreatment. An improvement was observed in serum creatinine levels (76.2% of patients), decreasing from a median of 1.58 to 1.45 (IQR [1.0-2.1] to [1.1-1.9]) over 12 months (p = .054). eGFR improved at 3 and 6 months compared with 3 months pre- BTC levels; however, this was not statistically significant (p = .24). Treatment discontinuation occurred in seven patients (33.3%) of whom four (19%) were switched back to full dose CNI. Infections occurred in 11 patients (52.4%), leading to BTC discontinuation in 4 patients (19%). CONCLUSION In this cohort, BTC therapy was used as alternative immunosuppression for management of highly sensitized patients or for renal sparing. BTC therapy when combined with CNI dose reduction resulted in stabilization in renal function as measured through renal surrogate markers, which did not, however, reach statistical significance. Patients on BTC maintained a low rejection rate and preserved graft function. Infections were common during BTC therapy and were associated with medication pause/discontinuation in 19% of patients. Further randomized studies are needed to assess the efficacy and safety of BTC in HT recipients.
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Affiliation(s)
- Daniel Oren
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Matan Uriel
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Cathrine M Moeller
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Andrea Fernandez Valledor
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
| | - Ersilia M DeFilippis
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Dor Lotan
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Kevin J Clerkin
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Jayant K Raikhelkar
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Justin A Fried
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - David Kyung Taek Oh
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - David Bae
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Eddie Lin
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Kleanthis Theodoropoulos
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Koji Takeda
- Department of Cardiothoracic Surgery, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Jason Choe
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Douglas L Jennings
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - David Majure
- Division of Cardiology, Advanced Cardiac Care, Weill-Cornell Medical College, New York, New York, USA
| | - Farhana Latif
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
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Rubinstein G, Moeller CM, Lotan D, Slomovich S, Fernandez-Valledor A, Oren D, Oh KT, Fried JA, Clerkin KJ, Raikhelkar JK, Topkara VK, Kaku Y, Takeda K, Naka Y, Burkhoff D, Latif F, Majure D, Colombo PC, Yuzefpolskaya M, Sayer GT, Uriel N. Hemodynamic Optimization by Invasive Ramp Test in Patients Supported With HeartMate 3 Left Ventricular Assist Device. ASAIO J 2024:00002480-990000000-00420. [PMID: 38373176 DOI: 10.1097/mat.0000000000002167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
In patients supported by the HeartMate 3 left ventricular assist device (HM3 LVAD), pump speed adjustments may improve hemodynamics. We investigated the hemodynamic implications of speed adjustments in HM3 recipients undergoing hemodynamic ramp tests. Clinically stable HM3 recipients who underwent routine invasive hemodynamic ramp tests between 2015 and 2022 at our center were included. Filling pressure optimization, defined as central venous pressure (CVP) <12 mm Hg and pulmonary capillary wedge pressure (PCWP) <18 mm Hg, was assessed at baseline and final pump speeds. Patients with optimized pressures were compared to nonoptimized patients. Overall 60 HM3 recipients with a median age of 62 years (56, 71) and time from LVAD implantation of 187 days (124, 476) were included. Optimized filling pressures were found in 35 patients (58%) at baseline speed. Speed was adjusted in 84% of the nonoptimized patients. Consequently, 39 patients (65%) had optimized pressures at final speed. There were no significant differences in hemodynamic findings between baseline and final speeds (p > 0.05 for all). Six and 12 month readmission-free rates were higher in optimized compared with nonoptimized patients (p = 0.03 for both), predominantly due to lower cardiac readmission-free rates (p = 0.052). In stable outpatients supported with HM3 who underwent routine ramp tests, optimized hemodynamics were achieved in only 2 of 3 of the patients. Patients with optimized pressures had lower all-cause readmission rates, primarily driven by fewer cardiac-related hospitalizations.
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Affiliation(s)
- Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sharon Slomovich
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Andrea Fernandez-Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kyung T Oh
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | | | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - David Majure
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Rubinstein G, Moeller CM, Lotan D, Slomovich S, Fernandez-Valledor A, Ranard LS, Leahy NE, Ladanyi A, Oren D, Clerkin KJ, Raikhelkar JK, Topkara VK, Fried JA, Vahl T, Colombo PC, Kaku Y, Takeda K, Naka Y, Yuzefpolskaya M, Sayer GT, Uriel N. The Hemodynamic Effects of Aortic Regurgitation in Patients Supported by a HeartMate 3 Left Ventricular Assist Device. J Card Fail 2024; 30:95-99. [PMID: 37625582 DOI: 10.1016/j.cardfail.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Aortic regurgitation (AR) is a common complication following left ventricular assist device (LVAD) implantation. We evaluated the hemodynamic implications of AR in patients with HeartMate 3 (HM3) LVAD at baseline and in response to speed changes. METHODS AND RESULTS Clinically stable outpatients supported by HM3 who underwent a routine hemodynamic ramp test were retrospectively enrolled in this analysis. Patients were stratified based on the presence of at least mild AR at baseline speed. Hemodynamic and echocardiographic parameters were compared between the AR and non-AR groups. Sixty-two patients were identified. At the baseline LVAD speed, 29 patients (47%) had AR, while 33 patients (53%) did not. Patients with AR were older and supported on HM3 for a longer duration. At baseline speed, all hemodynamic parameters were similar between the groups including central venous pressure, pulmonary capillary wedge pressure, pulmonary arterial pressures, cardiac output and index, and pulmonary artery pulsatility index (p > 0.05 for all). During the subacute assessment, AR worsened in some, but not all, patients, with increases in LVAD speed. There were no significant differences in 1-year mortality or hospitalization rates between the groups, however, at 1-year, ≥ moderate AR and right ventricular failure (RVF) were detected in higher rates among the AR group compared to the non-AR group (45% vs. 0%; p < 0.01, and 75% vs. 36.8%; p = 0.02, respectively). CONCLUSIONS In a cohort of stable outpatients supported with HM3 who underwent a routine hemodynamic ramp test, the presence of mild or greater AR did not impact the ability of HM3 LVADs to effectively unload the left ventricle during early subacute assessment. Although the presence of AR did not affect mortality and hospitalization rates, it resulted in higher rates of late hemodynamic-related events in the form of progressive AR and RVF.
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Affiliation(s)
- Gal Rubinstein
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York.
| | - Cathrine M Moeller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Dor Lotan
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Sharon Slomovich
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | | | - Lauren S Ranard
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Nicole E Leahy
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Annamaria Ladanyi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Daniel Oren
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Jayant K Raikhelkar
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Justin A Fried
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Torsten Vahl
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
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Moeller CM, Valledor AF, Oren D, Rubinstein G, Sayer GT, Uriel N. Evolution of Mechanical Circulatory Support for advanced heart failure. Prog Cardiovasc Dis 2024; 82:135-146. [PMID: 38242192 DOI: 10.1016/j.pcad.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 01/21/2024]
Abstract
This comprehensive review highlights the significant advancements in Left Ventricular Assist Device (LVAD) therapy, emphasizing its evolution from the early pulsatile flow systems to the cutting-edge continuous-flow devices, particularly the HeartMate 3 (HM3) LVAD. These advancements have notably improved survival rates, reduced complications, and enhanced the quality of life (QoL) for patients with advanced heart failure. The dual role of LVADs, as a bridge-to-transplantation and destination therapy is discussed, highlighting the changing trends and policies in their application. The marked reduction in hemocompatibility-related adverse events (HRAE) with the HM3 LVAD, compared to previous models signifies ongoing progress in the field. Challenges such as managing major infections are discussed, including innovative solutions like energy transfer systems aimed at eliminating external drivelines. It explores various LVAD-associated complications, including HRAE, infections, hemodynamic-related adverse events, and cardiac arrhythmias, and underscores emerging strategies for predicting post-implantation outcomes, fostering a more individualized patient care approach. Tools such as the HM3 risk score are introduced for predicting survival based on pre-implant factors, along with advanced imaging techniques for improved complication prediction. Additionally, the review highlights potential new technologies and therapies in LVAD management, such as hemodynamic ramp tests for optimal speed adjustment and advanced remote monitoring systems. The goal is to automate LVAD speed adjustments based on real-time hemodynamic measurements, indicating a shift towards more effective, patient-centered therapy. The review concludes optimistically that ongoing research and potential future innovations hold the promise of revolutionizing heart failure management, paving the way for more effective and personalized treatment modalities.
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Affiliation(s)
- Cathrine M Moeller
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Andrea Fernandez Valledor
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Daniel Oren
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Gal Rubinstein
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Advanced Cardiac Care, Columbia University Irving Medical Center, NY, USA.
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Oren D, Moeller CM, Haythe JH, Rubinstein G, Fernandez Valledor A, Lotan D, Rosenblum H, Colombo PC, Yuzefpolskaya M, Topkara VK, Clerkin KJ, Raikhelkar JK, Fried JA, Naka Y, Takeda K, Latif F, Sayer G, Uriel N. Pumping for Two: Pregnancy in Patients Supported With a Left Ventricular Assist Device. ASAIO J 2023:00002480-990000000-00346. [PMID: 37934714 DOI: 10.1097/mat.0000000000002082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
This review discusses the challenges and outcomes associated with pregnancy during left ventricular assist device (LVAD) support. Women account for a third of the heart failure population in the United States. Left ventricular assist devices have emerged as a safe and effective treatment option for patients with advanced heart failure. Pregnancy during LVAD support can occur, and it presents significant risks to both mother and fetus, including hemodynamic stress, thrombotic events, medication-associated teratogenicity, and uterine impingement. This literature review identified 10 cases of confirmed pregnancy during LVAD support, of which eight resulted in successful births. Maternal and fetal mortality occurred in one case, and there was a spontaneous abortion in one case. The review highlights the importance of a multidisciplinary approach, promotion of shared decision-making, thoughtful anticoagulation, adjustment of LVAD speed, and medication optimization to maintain hemodynamic support during pregnancy. Hemodynamic changes during pregnancy include increased cardiac output, heart rate, and plasma volume, as well as decreased systemic vascular resistance, which can impact LVAD support. Despite reduced pulsatility in LVAD-supported patients, ovulation and reproductive capacity might be preserved, and viable pregnancies may be achieved with appropriate management. The review provides insights into the risks and considerations for a viable pregnancy during LVAD support, including the need for ongoing research to inform joined decision-making.
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Affiliation(s)
- Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jennifer H Haythe
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Andrea Fernandez Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Hannah Rosenblum
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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Rubinstein G, Lotan D, Moeller CM, DeFilippis EM, Slomovich S, Oren D, Yuzefpolskaya M, Sayer G, Uriel N. Sex differences in patients undergoing heart transplantation and LVAD therapy. Expert Rev Cardiovasc Ther 2022; 20:881-894. [PMID: 36409479 DOI: 10.1080/14779072.2022.2149493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Left ventricular assist device (LVAD) and heart transplantation (HT) are the two life-sustaining therapies that have revolutionized the management of end-stage heart failure (HF). Yet, significant sex differences exist with respect to their use and effects. AREAS COVERED This review summarizes sex differences in the utilization, outcomes, and complications of LVAD and HT. Particular emphasis is placed on leading clinical trials in the field, historical and recent large registries-based analyses, as well as contemporary technological and policy changes affecting these differences. EXPERT OPINION Women with advanced HF remain under-treated with guideline-directed medical therapy and are less likely to be referred for consideration for LVAD and HT. This remains true despite newer LVAD technology and the new heart transplant allocation system. Community outreach, education, as well as increased representation of women in clinical research may reduce inequities.
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Affiliation(s)
- Gal Rubinstein
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Dor Lotan
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Cathrine M Moeller
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Sharon Slomovich
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Daniel Oren
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Gabriel Sayer
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
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Raphael R, Makmal NM, Silbermintz NS, Faierstein KF, Moeller CM, Canetti MC, Maor EM, Kuperstein RF, Hai IH, Butnaru AB, Oren DO, Guetta VG, Fefer PF. Outcome of trans-catheter edge-to-edge mitral valve repair in patients with severe left ventricular dilatation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
The COAPT trial established the benefit of trans-catheter edge-to-edge mitral valve repair (TEER) for patients with symptomatic secondary mitral regurgitation (MR). However, patients with severe LV dilatation were excluded from this study. Furthermore, disproportionate LV dilatation has been proposed as a possible explanation for the lack of benefit in the Mitra-FR trial.
Purpose
The purpose of this study was to evaluate the safety and efficacy of TEER in patients with severe LV dilatation.
Methods
We categorized patients with secondary MR and severe LV dilatation based on LVEDD/BSA ratio using a cut-off of >3.6cm/m2 in men and >3.7cm/m2 in women.
Results
We included 121 patients, 25 patients with severe LV dilatation (S) and 96 without (NS). Mean LVEDD was 68.9±6.6mm in the S group vs 58.5±6.5mm in the NS group. Compared to the NS patients, patients with severe LV dilatation were younger (age 69±10 vs 74±10 years), had lower LVEF (37+14% vs 29+7%), and lower GFR (44±21 vs 55±26). There was no significant difference in MR grade (3.3 vs 3.3), however the S group had numerically greater EROA (EROA 0.45 vs 0.35). No significant differences were noted in NYHA class (2.8 vs 2.76) or SPAP (59mmHg for both). Peri-procedural adverse events were rare in both groups. One peri-procedural death was noted, 2 patients underwent urgent dialysis, 1 had cardiogenic shock, and 2 had prolonged ventilation after the procedure, all of these occurred in the NS group. At 1-year follow-up, there was marked improvement in MR grade (2.4±1.4 vs 2.2±1.2 for S and NS respectively). Both groups had a small reduction in LVEDD of about 3mm. Patients in the S group had improved GFR at 1-year follow-up (44±21 to 51±32). No differences were noted in 1, 2, or 5 year mortality between groups (Figures).
Conclusion
Trans-catheter edge-to-edge mitral valve repair in patients with severe LV dilatation is safe and seems to provide similar short-and long-term outcomes compared to patients with less severe dilatation. Further studies are needed to establish the efficacy of TEER for these patients.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- R Raphael
- Sheba Medical Center , Ramat Gan , Israel
| | - N M Makmal
- Sheba Medical Center , Ramat Gan , Israel
| | | | | | | | | | - E M Maor
- Sheba Medical Center , Ramat Gan , Israel
| | | | - I H Hai
- Sheba Medical Center , Ramat Gan , Israel
| | | | - D O Oren
- Sheba Medical Center , Ramat Gan , Israel
| | - V G Guetta
- Sheba Medical Center , Ramat Gan , Israel
| | - P F Fefer
- Sheba Medical Center , Ramat Gan , Israel
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Nygaard TW, Beller GA, Mentzer RM, Gibson RS, Moeller CM, Burwell LR. Acute coronary occlusion with exercise testing after initially successful coronary angioplasty for acute myocardial infarction. Am J Cardiol 1986; 57:687-8. [PMID: 2937285 DOI: 10.1016/0002-9149(86)90861-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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